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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601141
Report Date: 12/21/2023
Date Signed: 12/21/2023 04:34:55 PM


Document Has Been Signed on 12/21/2023 04:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:SANDHILL ASSISTED LIVING LLCFACILITY NUMBER:
415601141
ADMINISTRATOR:TILMA, SUSANFACILITY TYPE:
740
ADDRESS:1239 MIDDLE AVETELEPHONE:
(650) 796-9921
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:6CENSUS: 5DATE:
12/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:56 PM
MET WITH:Ricardo AbanTIME COMPLETED:
03:45 PM
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On 12/21/23 Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management visit. LPA met with Administrator Ricardo Aban and explained the purpose of the visit.

LPA checked if the Decision and Order to exclude and individual was followed effective today, 12/21/23. LPA toured and checked the facility and everything is clear. Individual is no longer in the premises.

Report is reviewed and copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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